Thousands of nurses--7,560, to be exact--completed the AJN Patient Care Survey,
which was published in the March 1996 issue of AJN. It's the largest survey of
nurses' views on health care and nursing practice ever conducted. Nurses
responded from every state and territory in the United States and represented a
wide range of positions and specialties. Your participation, and your detailed
comments describing conditions in your workplace, have given us the best
picture to date of what's happening in the U.S. health care system and in your
practice.
It's a picture with some commonalties. Nurses across the nation, in every
setting and specialty, report that they're taking care of more patients, have
been cross-trained to take on more nursing responsibilities, and have
substantially less time to provide all aspects of nursing care. But it's also
a picture noteworthy for the differences--across regions of the country,
settings, specialties, and positions. Other key findings include:

* Almost half of the nurses reported that part-time or temporary RNs
have been substituted for full-time RNs, and two out of five reported the
substitution of unlicensed assistive personnel for RNs. Significantly higher
rates of substitution were reported by nurses in the Pacific region. The
greatest cutbacks in RN staffing were reported by nurses in the Northeast and
East/North Central regions. These three regions--the Pacific, Northeast, and
East/North Central--lead the nation in terms of the percentage of their
population that is covered by managed care insurers.

* Over half of the nurses reported less continuity of care and an
increase in unexpected readmissions, with significantly higher percentages
reported by nurses in the Northeast and Pacific regions. Two-thirds of
emergency and psychiatric/mental health nurses also reported increased
unexpected readmissions. Most geriatric nurses and two out of five ICU/CCU
nurses reported increases in complications secondary to admitting diagnosis.

* Nurses' perceptions of quality in home/community care and subacute
care facilities varied widely. Two-thirds of home care nurses stated that the
quality of care met their professional standards, compared with only one-third
of nurses in subacute care.

* Only three-quarters of nurses stated they would remain in nursing,
with the fewest in the Pacific region. In Massachusetts--the state hit hardest
by recent cutbacks in RNs--the number of nurses stating that they were going to
leave the profession has increased fivefold in less than two years. Many
nurses said in their written comments that they were going to leave nursing
because they couldn't provide patients with adequate nursing care in the
current health care environment.

* Nearly two out five nurses said they wouldn't want a family members
to receive care at their organization.

How to explain these findings, and what implications they have for the demand
for nurses and quality of patient care in the future, is the focus of this
article.

The AJN Patient Care Survey deals mainly with three aspects of the
health care delivery system--the structure of services provided and
the process and outcomes of nursing care. We first asked nurses how
the system's infrastructure and the use of nursing personnel have
changed in the past year. The answers may seem obvious--after all,
who in the health care profession hasn't witnessed remarkable
changes? But never before have so many nurses explicitly stated
what those changes are.

There were some areas in which nurses' responses were similar
across the country--for example, in initiating construction or
renovation (66%), establishing/acquiring community-based services
(43%), and loss of managed care contracts (14%). And nurses
everywhere reported in overwhelming numbers that they're taking
care of more patients (66%) and have been cross-trained to take on
more responsibilities (59%).

Nurses' responses also suggest that efforts to increase productivity
through "speed ups"--expecting fewer workers to work harder and
do more--aren't confined simply to nurses at the bedside. Nurses at
all levels are feeling the effects of downsizing, with almost half (45%)
reporting cuts in nurse mangers and almost two out of five (38%)
reporting losing a nurse at the executive level without replacement.
Prospects for nurses in advanced practice may not be as optimistic as
once predicted, with only 12% of respondents stating there are more
positions for APNs.

While we found these and other commonalties, in other areas we
found dissimilarities in nurses' reports by region, setting, and
specialty. This may explain why it's been difficult to reconcile the
apparent contradictions between what nurses are saying anecdotally
and national data in the aggregate on nursing manpower trends.
Overall, more than half (56%) of the respondents reported that their
health care organization has closed beds or units within the past
year. Although two-thirds of nurses in the Northeast and Mid-
Atlantic regions reported such cutbacks, only two out of five nurses
in the Mountain and West/South Central regions reported them.
Even as the health care system downsizes, almost an equal number
(51%) of nurses across the country reported their health care
organization is adding services. There were wide variations,
however, between the West Coast and the South. In the Pacific
region, only 43% of the respondents reported their organization is
adding services, compared with 57% of nurses in the South Atlantic
region and 56% of nurses in the East/South Central and West/South
Central regions.

How do we know that nurses' responses to the AJN Patient Care
Survey is an accurate portrayal of what's happening in our health care system
as a whole, in our nursing practice, and to our patients? By comparing the
responses with information from national databases, we can judge how closely
nurses' perceptions match other sources.

The most relevant and recent secondary data sources are from the
American Hospital Association's "Annual Survey of Hospitals" and the
foolproof validation methods. Some critics might claim that these
"hard" data, especially those gathered by the AHA, are potentially
more biased and fraught with problems of manipulation than what's
gleaned by simply asking nurses to report what they see. Also, the
most recent data available were collected in 1994, and with the
volatility of the health care system there's the risk that changes
reported by nurses today won't be reflected in data sources dating
back two years. But even with these limitations, they're the best
secondary sources of information available, so we've used them to
compare the reports of nurses in the AJN survey.

On the whole, findings in the AJN survey show a striking similarity to
trends identified by these sources. According to the 1996 AHAHospital Stats, which is the published report of the "Annual Survey
of Hospitals," declines in the number of hospital beds varied from
region to region, with the greatest losses occurring along the coasts
and in the East/North Central region. The primary factor driving
down hospital utilization is managed care, and downsizing has
occurred most intensely in regions where a higher percentage of the
population is covered by managed care insurers--specifically, the
coasts and the East/North Central region.

While the AHA anticipates that declines in the number of U.S.
hospitals will level off in the 1990s, it's unlikely that any regions of
the country will be immune from hospital downsizing and
restructuring. Hospital bed or unit closures are likely to intensify in
regions with a combination of low managed care infiltration and high
percentage of hospital downsizing and restructuring. Hospital bed or
unit closures are likely to intensify in regions with a combinations of
low managed care infiltration and a high percentage of hospital beds
per population--specifically, the Mid-Atlantic, West/North Central,
and East/South Central regions. One mitigating factor may be the
consolidation of health care services through mergers. In the AJN
survey, nurses in the West/North Central region reported
significantly more (55%) of mergers than nurses elsewhere.

While many of the structural changes we've described were undertaken to
integrate the process of health care, respondents to the AJN Patient Care
Survey suggest that just the opposite is occurring. A surprising 55% of nurses
across the U.S. reported that there's less continuity of care, and an
overwhelming number of nurses reported having less time to provide all aspects
of nursing care. For example, most RNs reported less time to teach patients
and their families (73%) comfort and talk to patients (74%), provide basic
nursing care (69%), document care (66%), and consult with other members of the
health care team (57%).

The substantial reduction in the time nurses have to care for patients
is probably due to a combination of factors, including cuts in the
overall number of RNs, more patients assigned to each RN, shortened
length of stay, and rising acuity. After 10 years of steady,
incremental declines in length of stay, the AHA found in 1994 that
length of stay in community hospitals had fallen a dramatic 4.3%.
Consistent with this trend, 66% of the participants in the AJN survey
reported declines in length of stay and 77% reported increases in
patient acuity.

Such a significant one-year drop in hospital length of stay occurred
only once before, when DRGs were introduced in the mid-1980s. The
latest plunge is also most likely due to changes in health care
financing--specifically, the nationwide move toward managed care. A
1995 report from Congressional Budget Office found that while HMOs
increased the use of outpatient services by 3% over traditional fee-
for-service plans, on average HMOs used 34% less inpatient care. The
CBO report emphasized that at least half of the reduction in medical
costs achieved by HMOs came from cutting length of hospital stay for
childbirth.

The ratcheting down of length of stay has triggered an outcry from
the public and providers that profits are superseding the needs of
patients. In free-market economies, one of the central roles of
government is to balance the interests of business, and workers, and
consumers. As the corporatization of health care has escalated, so too
have the number of state and federal regulations designed to rein in
the actions of managed care organizations and safeguard the public.
For example, President Clinton has signed into law a bill eventually
passed by Congress guaranteeing coverage for two-day stay after
childbirth.

It's conceivable that the legislative reforms sweeping the country
could stabilize hospital length of stay. The findings in the AJN
Patient Care Survey suggest that the need for regulatory safeguards
is greatest for consumers in the Northeast and Pacific regions. Nurses
in these regions reported significantly higher levels (68% and 60%,
respectively) of unexpected readmissions. While in some instances
the Northeast has led the nation in enacting legislative reforms
designed to empower patients and improve access to care, the Pacific
region has notable lagged behind the rest of the country. However,
two health care referendums mandating a variety of regulatory
protections were put on the California ballot for public vote this
month.

Newborns and their mothers have been the focus of regulations
mandating hospital length of stay, and the lowest rates of
readmission reported in the AJN survey (39%) were by
obstetrics/gynecology nurses (n=478). We can't infer from this
finding that state regulations have been an effective deterrent to the
premature discharge of mothers and babies. However, we were
interested in whether there might be other vulnerable populations
who could benefit from such reforms.

When we examined the incidence of unexpected readmissions by
specialty, increases were concentrated in two specialty areas. Sixty-
eight percent of emergency nurses (n=396) and 63% of
psychiatric/mental health nurses (n=476) reported increases in
unexpected readmissions, compared with 55% of nurses in all other
specialties. Samuel and colleagues reported this past spring that
among psychiatric patients, younger patients had the highest rates of
hospital readmission. These findings are consistent with a 1995
study investigating the impact of managed care on psychiatric
treatment reported in Health Affairs , which found that psychiatric
readmission rates were highest for children and adolescents.
While younger patients may be at greatest risk for psychiatric
readmissions, Safran and colleagues reported in a large retrospective
study of 5,000 emergency readmissions that patients who were at
greatest risk were older and had longer hospitalizations and higher
hospital charges. More recently, Fransworth and colleagues found
that 50% of elderly patients discharged from the emergency
department deteriorated at home due to lack of community support,
and 5.6% required rehospitalization.

Whether mandating length of hospital stay for postpartum women
has any demonstrable clinical benefit continues to be hotly
debated. But there may be other populations at risk for premature
discharge--specifically, children and young adults seeking psychiatric
treatment and the elderly. From a public perspective, of all our
citizens, those at either end of the age spectrum are sometimes the
least capable of advocating for themselves and the most in need of
regulatory protections.
With every well-intentioned regulation enacted by government, of
course, there's a clever consultant who manages to find a loophole.
So it's entirely possible that as more regulations proscribe the
conditions under which hospital care will be provided, patients will
be shifted to other settings. Even before the rash of mandates on
hospital length of stay, managed care providers were transferring
more patients to sub acute and intermediate care facilities because of
the perceived cost savings.